10 Phone Version_Parent or Guardian Permission form for Acc

OMB Number (0915-0368)
Expiration date (03/31/2023)

Public Burden Statement: The information collected through the Health Center Patient Survey (HCPS) informs HRSA on how health centers provide access to primary and preventative health care from the patients’ perspectives. It is the only nationally-representative survey of its type that focuses on the health care of populations seeking care at health centers. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0368 and it is valid until 03/31/2023. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.

Parent/Guardian Permission Form for
Accompanied Adolescent (Ages 13–17) Survey Participation
Health Center Patient Survey

About the Survey

The Health Center Patient Survey is a research study being conducted by RTI International. The survey is sponsored by the Health Resources and Services Administration (HRSA). The survey is about people who receive health care at places like your health center. The survey will try to find out what kinds of health problems people have and how well the health centers are meeting the needs of the people who use them. Your child is one of 9,000 people that RTI has chosen to participate.

Adolescent Participation

If your child agrees to participate, he/she will be asked some questions about his/her health and the services that he/she receives at the health center. Some of the questions may be personal, such as questions about your child’s emotions or feelings. There also may be questions about HIV/AIDS and thoughts about suicide. Most of the questions are about less sensitive things like health care received and whether your child has certain health conditions like asthma or diabetes. Some people will get a shorter interview, while others will take a bit longer. The adolescent interview may last about 40 minutes.

Parent/Guardian Participation

There are several questions that we would like to ask of you. For example, these are questions about family health insurance coverage, household income and sources of income, and a few questions about you such as marital status and veteran status. These questions will take about 10 minutes and can be completed prior to or after the adolescent interview.

Voluntary Participation

Your child may choose whether or not he/she would like to participate. If you choose not to give us permission or if your child chooses not to participate, it will not affect any services your child or your family may receive at the health center or from any other programs. If your child does not want to answer some of the questions he/she is asked, that is okay. If your child decides not to finish the questions, that is okay too. You may also choose whether to complete your component of the interview. We can conduct the interview with your child regardless of whether you complete your part of the interview.

Benefits

There are not any direct benefits to you or your child. However, he/she will be helping us learn more about the health needs of people who use health centers like the one you visit.

Compensation for Participation

In addition, if your child participates, he/she will be provided with $25 gift card, check or a gift of equal value to thank him/her for his/her time.

Risks of Study Participation

There are two potential risks involved in study participation that we are aware of. One risk is that the questions we ask might make your child feel uncomfortable or upset. If your child feels uncomfortable or upset, he/she may ask the interviewer to take a break or to skip any of the questions. The other risk is that someone might find out what your child told us during the interview. To avoid that, we will ask her to do the interview in private place in your home where no one can hear his/her answers. We will also create and use a number instead of your child’s name to identify your child’s interview. This will prevent anyone from finding out what your child’s answers were.

Your Child’s Privacy

Anything your child tells me is private. The privacy of his/her answers is very important, so let me say a little more about it. I am going to enter your child’s answers into the computer. As mentioned, your child’s answers will be linked to a number instead of his/her name so no one else will know he/she answered the questions. The staff involved in this research has signed an agreement stating they will protect the privacy of the information provided. The information that your child tells me will not be shared with you or anyone at the health center. We will not ask your child about his/her legal or immigration status.

Exceptions to Privacy Pledge

There is an important exception. If I learn through the course of the interview that your child’s life or health, or another person’s life or health could be in danger, I may be required to inform the clinic staff or the proper authorities.

Questions

If you have any questions about this study, you may call Azot Derecho, Data Collection Task Leader at 1 (800) 334-8571 Ext 27231. If you have any questions about your rights as a study participant, you may call RTI’s Office of Research Protections toll-free at 1 (866) 214-2043.

Recordings

We are using a special quality control system on this project. The system runs on the computer and will record what your child and I say to each other during several different parts of the interview. Neither your child nor I will know when the computer is recording what we say. The recording will be reviewed by people at RTI to monitor my work and will be kept private. Your child may participate in the interview even if you do not consent to the recordings. May we use this quality control system during your child’s interview?